Edited by: Annet De Lange, Open University of the Netherlands, Netherlands
Reviewed by: Takuma Kimura, Hosei University, Japan; Kevin Rui-Han Teoh, Birkbeck, University of London, United Kingdom
This article was submitted to Organizational Psychology, a section of the journal Frontiers in Psychology
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Research indicates that the active support of managers is essential for the sustainable implementation of health-related work design interventions in organizations. However, little is known about managers’ perceptions of such health promotion measures.
Our study aims to provide information that help to foster managers active support of health-related work design interventions in hospitals. Based on Ajzen’s Theory of Planned Behavior (TPB) we explore the attitudes, perceived organizational norms, and perceived behavioral control of managers in the hospital regarding such interventions.
Semi-structured interviews with 37 managers (chief physicians, senior physicians, and senior nurses) were carried out in one German hospital. A software aided qualitative content analysis was applied.
We observed that the majority of managers are aware of the importance of health-related work design. We found a high variation in the perception of organizational norms related to mental health promotion of employees. Behavioral control for supporting interventions is perceived more on an individual (e.g., appraisal interviews, professional development or support) and team level (e.g., fair work schedule, regular team meetings), less on an organizational level.
To enable and to motivate hospital medical and nursing managers to support health-related work design, hospitals need to establish clear organizational norms that the health promotion of their employees is an important organizational goal. Moreover, managers need to get more work-design competencies and decision latitude to get more control. Important arguments for the top hospital management could be that health-related work design is highly effective for economic success, for treatment quality, and that the middle management already has a positive attitude toward the implementation of measures that help promote the mental health of their staff.
Physicians and nurses in hospitals are exposed to high work stress that puts them at risk for impaired well-being and health (
Studies demonstrate that high workload, time pressure, work interruptions, high work demands with low control, mismatch between effort and return, insufficient social support or poor management style impair the mental health of employees in hospitals (
Therefore, for hospitals the implementation of occupational health promotion interventions becomes increasingly important to ensure the well-being and employability of their staff, and to ensure the safe care of their patients. An essential part of occupational health promotion interventions, are health-related work design interventions, also called organizational or organizational-level interventions (
Notwithstanding the importance of such interventions, a significant lack of effective and well-evaluated health-related work design interventions in health care settings and beyond has been deplored for years (
Recent organizational studies point out the importance of the active support of managers for a successful implementation of such interventions (
Against this background, the aim of our qualitative study is to examine medical and nursing managers’ perception of health-related work design interventions in the hospital based on the TPB. To the best of our knowledge, we present the first study that examines the perspective of hospital managers on such interventions. With this systematic qualitative analysis, our study aims to contribute to the further theoretical and conceptional underpinning of the design and successful implementation of much needed work design interventions in hospitals.
Available organizational research in this context is mainly focused on the
Recent studies suggest that the so far rather ambiguous results on the effectiveness of health-related work design measures can be explained by systemic or contextual factors (
Current implementation research clearly shows that support from managers is one of the key factors for the success or failure of organizational interventions (
These findings are important because organizational interventions that reported no, moderate or indifferent effects often argue with a lack of support from managers (
The Theory of Planned Behavior (TPB) (
In a meta-analytical review of 185 independent studies,
Based on the above-mentioned findings we consider the TPB model as particularly well suited for our research context. It can represent the perceptions of managers concerning the implementation of health-related measures to support the mental health of employees. The TPB has not yet been taken up frequently in organizational contexts. There are first studies that make use of the theory to examine the intentions of employees to turn over or employees’ career choice and development behavior (
We identified three quantitative studies using TPB in the context of health-promoting interventions at work (
Besides,
The third study (
All three studies show that attitudes significantly predict the intention to support or participate in health-promoting measures. If managers or employees perceive a benefit, it is more likely that they will be committed to health-promoting work design measures. Concerning organizational norms, the studies report slightly different results.
Based on these previous findings (
They consider organizational mental health promotion to be important and feel morally responsible for it (
There are
They think that they possess internal or external resources to improve working conditions (
Accordingly, we developed our research questions, based on the three predictors of the TPB
Research model based on the Theory of Planned Behavior (TPB;
The present interview study aims to fill a research gap by approaching the managers’ perspective toward mental health promotion by work design. While the previous studies on TPB in the context of health-promoting interventions at work focused on individual-related interventions or individual leadership behavior, we focus on the role of leaders in the implementation of organizational level work design interventions. Moreover, especially with regard to hospital managers, there seems to be a research gap, as we have not been able to identify a study that includes this group of managers. In line with existing studies, we hereby capture the specific perspectives of medical and nursing managers to take into account the differing roles and responsibilities of different groups of managers (
Considering the so far sparse research on that topic we believe that a qualitative design will be particularly suitable for further theory building, as its openness and flexibility allow a better insight into the subjective perspective of the respondents and their patterns of thought and interpretation.
We conducted semi-standardized individual interviews in German language with upper medical managers (chief physicians), middle medical managers (senior physicians) and middle nursing managers (senior nurses) of a German hospital with two locations, belonging to a larger corporate organization. The larger clinic has approximately 500 beds and employs approximate 700 physicians and nursing staff. The smaller one has around 350 beds and about 450 medical and nursing employees and was converted from a specialized clinic to an emergency/casualty hospital.
In German hospitals a chief physician is the head of a department within a hospital (e.g., surgical department, psychiatric department). She or he is responsible for personnel management, the coordination of patient treatment, and budgeting in her or his department. Beside this management tasks a chief physician also participates directly in the patient treatment. The proportion of management tasks is about 70% in bigger hospitals, only 30% in smaller ones (
Our interview study has been proven by the ethic committee of the University Düsseldorf. In addition, we informed the hospital’s works council and the data protection authorities about the contents and the course of the study. All consents were available before the interviews were conducted.
We present the key results of the interviews along with the category system described in
Category system for interview analysis.
Belief in importance of mental health | The managers’ belief in the importance of employee mental health. | The mental health of employees is a very important issue for me, which is neglected in everyday life. But there is a great need for it (SP 37). | How important is the mental health of employees in your hospital? −>Own attitude to the topic | Attitudes that extend beyond health-promoting leadership behavior. Indirect formulations that are subject to interpretation. |
Belief in role | The manager’s belief in whether the promotion of employee health is the responsibility of the manager. | It is not only the task of the supervisor to pay attention to the employee’s health, but also vice versa. We do not differentiate, we are all involved in people, whether nurses in training or senior physicians (SP 37). | How would you describe your role as a supervisor for the mental health of your employees at work? | |
Belief in outcome of work design | The manager’s belief that work design measures have a positive or negative effect on the health of employees. | For me, it is a quality if we can openly communicate mistakes, uncertainties or the need for support. I believe that working in flat hierarchies also makes us better as a team (SP 34). | What stressors are the most important and which working conditions do you consider supportive and motivating for your employees? Do you see a connection between the stressors you have just mentioned and the mental health of your employees? | |
Norms of the upper hospital management | Perceived social pressure or organizational standards of hospital management that influence managers in their behavior to promote mental health. | I feel that the issue of mental employee health is not a priority for the upper hospital management (SP 33) | How important is the mental health of employees in your hospital? | Statements with managers’ own attitude to the topic. |
Norms of the colleagues | Perceived social pressure or organizational standards of colleagues that influence managers in their behavior to promote mental health. | I think it’s very important to everybody. I think that people deal with it in very different ways (CP 07) | What opinions do your colleagues have on the subject? | |
Internal focus | The manager’s experience of self-efficacy and/or sense of control for the implementation of work design measures by his own resources. | It motivates employees when you give them confidence and let them make their own decisions, but stand behind them (SP 38). | What changes do you think can be implemented to reduce the strain on your employees in their day-to-day work? What opportunities do you see for yourself to maintain the ‘mental’ health of your employees and to reduce the stressors you mentioned? | Statements related to employee activities. |
External focus | The manager’s experience of self-efficacy and/or sense of control for the implementation of work design measures in connection with organizational possibilities and limits. | In the age of a shortage of skilled workers we are whistling from the last hole. I wish I could, but there’s no time for team reflection. What we can do to minimize stress. We don’t do this enough; we should do it more often (SP 37). | Statements related to employee activities. External factors that can be influenced by managers −>Internal factors |
Concerning the variable
As described above, we further assessed internal and external factors related with
The data collection took place from April to July 2018. We recruited chief physicians (upper management), senior physicians (middle management) and senior nursing staff (middle management).
Participation was voluntary but recommended by the hospital managing director, medical directors and nursing service management. The participants were allowed to conduct the interviews during their working hours. We recruited the participants in various ways: (1) Information about the interview study at meetings of chief physicians and senior nurses, (2) Sending participant information about the interview study and reminder by e-mail and, (3) Appointment coordination by telephone after expression of interest by the managers, partly via secretarial offices. We informed the participants about the data protection and privacy; participants had to sign a letter of informed consent before start of the interview. The interviews were carried out “Face-to-Face” within the hospital. It was almost always possible to conduct the interviews without interruption (e.g., through emergency treatment). By approval of the managers, the conversations were audiotaped. The interviews lasted on average 45 min. They were conducted by a certified pedagogue with systemic qualification, a psychologist and a medical student which is also an examined nurse. All interviewees explained their background and stated that there might be clarifying questions about specific professional issues. The expert role was assigned to the participants.
We used an interview guide as a basis for the interviews. For introduction, we asked the managers about their perception of the most important organizational stressors and resources for their employees:
A draft of the interview guide was discussed by the study team. It was afterward tested in an expert interview with a doctor from one university hospital and then slightly modified. The interview study was conducted by three interviewers of the study team. After the conduction of the first six interviews, we consolidated whether it was necessary to make further modifications. No changes to the guide were necessary. The interviews were conducted until the point of “theoretical saturation” was achieved. Glaser and Strauss defined this as points of analysis at which ‘no additional data are being found whereby the researcher can develop properties of the category. As he sees similar instances over and over again, the researcher becomes empirically confident that a category is saturated. When one category is saturated, nothing remains but to go on to new groups for data on other categories, and attempt to saturate these categories also’ (
The transcription of the digitally recorded interviews was acquired by a transcription office and then analyzed by the study team using structuring content analysis (
We interviewed 37 managers, including 23 medical professionals (14 chief physicians, CP, out of total 29; 9 senior physicians, SP, out of total 20) and 14 senior nurses (out of total 44). The interviewees work in different medical departments, shown in
Sample of the study.
Number | 14 | 9 | 14 |
Female | 2 | 2 | 9 |
Male | 12 | 7 | 5 |
Age range | 43–60 years | 38–60 years | 34–60 years |
Departe-ments | Anesthesia, dermatology, gynecology, vascular surgery, cardiology/intensive care medicine, pediatrics and juvenile medicine, hospital hygiene, hand and plastic surgery, pneumology and sleep medicine, radiology, spinal surgery, vascular surgery, psychiatry, urology, internal medicine. | Anesthesia, cardiology, neurology, pneumology and sleep medicine, spinal surgery, urology, hand and plastic surgery. | Oncology and hematology, pediatric and youth intensive medicine, anesthesia, occupancy management, sleep laboratory, internal intensive medicine, trauma surgery, general surgery, pediatrics and youth medicine, spinal surgery, geriatrics and psychiatry. |
In general, we found that the managers are sensitized to the importance of the mental health of employees. They place great importance on the topic of mental health in the hospital. Despite the high relevance, managers repeatedly stated that the topic is often neglected in their work routines. We did not observe major differences in the responses between the occupational groups.
Almost without exception chief physicians, senior physicians and senior nurses feel responsible or co-responsible for the mental health of their staff, even if the top priority is good patient care. They see themselves in the duty of care, want to make sure that the employees are doing well or want to be a role model, which is being perceived as a troubling role conflict by some of them. Participants report, that it is not always easy to reconcile the demands of economic efficiency and the assurance of good patient care while at the same time being a good role model for employees. The personal work demands and responsibilities are often high, which is why everyone has to take care of everyone: managers for employees and vice versa.
Even if everyone feels responsible, managers describe differentiated understandings of their roles. These are dependent on the work situation and are reflected in examples of behavior. These roles range from more protective roles:
“
or supportive roles:
up to more promotive roles:
or demanding roles:
Only one chief physician thinks that the responsibility belongs to each individual. He perceives himself rather helpless in the role of a manager. Another senior physician describes a common responsibility with a focus on occupational medicine and upper management.
In general, we can report that managers are aware of the interdependencies between working conditions and the mental health of employees.
Managers mention a range of job characteristics or approaches of work design that they believe have an impact on the mental health of employees. They particularly describe interactional or social supportive approaches for health promotion in hospitals, like the assisting with tasks or employee appraisals. Less often approaches for structural work design are mentioned, like changing work tasks or work processes. Additionally, to the mental health-promoting effects, managers also mention motivational, economic or patient-related effects which they attribute to work design measures as well.
The following
Managers’ focus on health-related work design measures.
Respectful and appreciative teamwork Development of a functional team with flat hierarchical and social supportive structures Appropriate distribution of tasks and job autonomy Simplification and relocation of administrative tasks Opportunities for occupational and personal learning and development Functioning interdisciplinary cooperation, communication and workflows Flexible working time models, staff-oriented shift schedules and break times Meaningful work Team justice Good leadership behavior |
The majority of managers describe health-related benefits of effective teams with social support structures. This social support can be individual or team-related.
In comparison to the other occupational groups, senior physicians more often mention the benefits of flat hierarchical structures. Some of them report from experiences of their own departments, others with a view to other departments of whom they believe that strong hierarchies are still existing.
A functioning interdisciplinary cooperation, transparent communication and workflows are starting points for many managers to avoid stress for employees.
Another important approach across all occupational groups is the design of flexible working time models, staff-oriented shift schedules and break times. Even if there are managers who disagree, the majority of the interviewees agree that it is becoming increasingly important to develop working time models that are more focused on the work-life balance and lifespan of employees.
In general, the interviewees see a strong association between mental health or well-being with job satisfaction, job motivation, and productivity. Especially chief physicians describe the connection between mental health, employee’s motivation and increased productivity in the economic context. In addition to the human perspective, chief physicians take on a stronger functional perspective on the impacts of work design measures. Moreover, they believe that a healthy working atmosphere has positive effects on the attractiveness of the hospital as an employer, on reduced fluctuation of employees or an increase in work performance.
Some interviewees additionally mention patient-related effects of work design, like the better quality of patient care or the reduction of complaints.
In a comparison of occupational groups, chief physicians more often establish functional connections between mental health and economic outcomes, which can be explained by the fact that they are in charge of budget responsibility and therefore are more strongly affected by financial-related role conflicts.
In summary, we found, that managers have very different perceptions of the
Most physicians and nurses believe that the topic of mental health promotion does not have a high importance/value for the upper hospital management (board of management and nursing service management). Instead, they believe that financial priorities are at the center of attention of the upper hospital management. Some managers suspect, that the hands of upper hospital management are also tied when trying to improve the working conditions for employees. The pressure of the employees may be perceived by the upper hospital management, but there seems to be a lack of practical solutions or ideas.
Those managers who have been working in the company for some time emphasize that the financial pressure has increased with the takeover of the corporate organization. Others merely assume that mental health promotion must be a upper hospital management subject matter because it is such a pressing issue. But it is not open communicated.
Some offers for employees’ health promotion are perceived by the interviewed managers, but they doubt whether they actually reach the employees. Some staff members introduce measures on their own initiative like running groups, etc.
It is assumed that health promotion measures are exclusively a matter of maintaining the work ability and performance. Some interviewees do not see any efforts from the upper hospital management at all. They think that the topic is ignored, and nothing is done. These managers describe a certain helplessness and frustration. More senior physicians than chief physicians seem to take this negative perspective. Some have the opinion that everyone has to deal with stress for themselves, it seems to be part of the job.
Few managers report that they have seen the upper hospital management as very supportive on the topic. They attribute this to their own personal experiences and report on situations in which they have experienced the upper hospital management as helpful.
At this level, we observed a difference between the physicians and nurses. While the nurses are convinced that their colleagues also consider the topic important and are interested in it (although it does not seem to be formally discussed), some physicians report on contrary attitudes of their colleagues. Especially for that occupational group, not all of them seem to think that mental health promotion is important.
What unites the occupational groups is the fact that the issue is only discussed informally among the colleagues.
“
Therefore, it seems to be a sensitive issue that is given importance, but generally it is not communicated in an open, well-structured and solution-oriented way.
The
Managers are most likely to experience internal behavioral control in social supportive measures on individual contact or at the team level. They report that it is helpful for themselves if they are in good and direct contact with the employees and notice problems at an early stage: e.g., stressful treatment cases or team conflicts. They experience self-efficacy when they are aware of their employees’ problems, and can actively address them. To some extent it is the offer of professional social support, but it is also the social-emotional social support in which the managers experience themselves effectively.
Some managers feel that it is a challenge to find a balance between supporting, demanding and encouraging their employees. Some consider it easier to relieve overworked employees, instead of helping them to cope with the demands for themselves. As a result, the managers must be careful not to reach their own limits.
Some interviewees report, that they benefit from their experience knowledge:
Others report benefits from their self-control and self-reflection skills. They perceive that they can control the workload by setting priorities to reduce stress for their employees. In this case, certain tasks are not being “sat out,” yet being moved down in the line of priority instead. A lack of managers’ ability to self-control can quickly lead to overwhelming the staff.
Finally, measures with a focus on justice, appreciation, and participation of employees were mentioned. Even if there is a general lack of functioning duty schedules in hospitals, managers see possibilities for action by letting employees participate to design and to ensure a most fair work time distribution. Appreciation can be given by managers in offering trainings, feedback, new tasks or job autonomy to employees.
The perception of managers’ behavioral control to implement work design measures is influenced, and often limited, by organizational factors. Restrictions for the implementation of work design measures are mainly perceived at the organizational level, partly also at the team level. Few managers perceive supportive organizational structures. The perceptions differ between occupational groups and across departments.
The managers perceive that high work intensity, the economic requirements, the lack of staff and missing job autonomy are the biggest challenges. These factors are often mentioned as difficulties to implement better working conditions by work design.
The development of functioning team structures is experienced as challenging or impossible, especially by physicians. The cooperation in the departments is characterized by continuous staff fluctuations. Various system-related reasons are mentioned. The medical training system requires a continuous change of personnel in the department. In-house rotations of the personnel are called complicating. Illness-related absences or dismissals aggravate the situation.
Two chief physicians describe limitations in team development because of the strict separation between care and medicine. In general, limited possibilities to participate in the recruitment and selection of staff are described. They feel externally determined by the upper hospital management or the nursing service management and restricted in their job autonomy.
Regular (interdisciplinary) team communication within flat hierarchical team structures are perceived by nursing staff and senior physicians as helpful in preventing work stress. While some managers perceive organizational structures that facilitate such an exchange, other managers describe their possibilities in that respect as limited. Senior physicians mention that due to the lack of communication in the team, many problems arise that have could have been avoided. Flat hierarchies are particularly appreciated by senior physicians and nurses but still not existing, which complicate the implementation of work design measures.
Managers experience the greatest challenge in designing cross-departmental cooperation. Interface problems are difficult to solve and the physicians in particular often complain about the lack of cooperation with managers from other departments. Solving interface problems take time, energy, persistence, and requires suitable organizational structures to work on coordinated changes. The complexity of organizational structures in the hospital makes improvements of working conditions more difficult.
In terms of this challenge, some interviewees see opportunities for chief physicians to form stronger alliances to bring across their common goals to the upper hospital management.
The cooperation with the upper hospital management is often perceived as restrictive and exhausting. Some managers point out that it takes a lot of time and effort to deal with the upper hospital management to get the problems solved. Others, who have made bad experiences in the support of the hospital management, seem resigned. They do not describe any possibilities on their own to change working conditions to the positive.
On the other hand, some managers benefit from the continuity in cooperative contact with upper hospital management or other stakeholders. A good and active contact with the upper hospital management or the nursing service management does not enable the direct implementation of improvements, but there is a perception that change processes can be initiated.
Organizational research has shown that the support from managers is one of the key factors for the success or failure of organizational interventions (
The results on
In accordance with previous studies (
In respect to
Due to the voluntary participation of managers in the interview study, we cannot rule out a sampling bias. We must assume that we have primarily reached those managers who had already positive attitudes toward the topic of employees’ mental health. Moreover, participants might have shown a socially desirable response behavior. Other recruitment settings (e.g., congresses, in-house trainings) or strategies (e.g., direct letters and financial compensation) might have led to a different selection of participants.
Since we only interviewed managers of one hospital, the results cannot be generalized without further ado. The interview guideline appears to be suitable for use in other hospitals, so that its generalizability could be tested. It should be also taken into account that the results of our study only describe the perception of medical and nursing management. No conclusions can be made about how the upper hospital management really acts to improve the mental health of employees. In a follow-up study the upper hospital management also might be asked about their perception toward the topic of mental health promotion (e.g., in a focus group) and then compared with the results of the medical and nursing management.
Moreover, the study design does not allow us to make any statements about the actual behavior of managers. We decided against the assessment actual behavior for several reasons: In the context of the interviews it is difficult to make valid statements about actual behavior. Conceptually, it is difficult to separate actual behavior in the interviews from the perception of “behavioral control.” In some cases we have concluded from reported behavior on PBC. Furthermore, quantitative studies have shown that the three predictors of the TPB can predict actual behavior. In view of the reference studies and our results, we assume that managers who report more positive attitudes, perceive supportive norms and behavioral control indeed design more health-promoting working conditions for their employees. We have retrospectively examined this assumption by additionally analyzing the interviews of two managers with contrary perspectives the TPB components (
Examples of managers’ statements with higher and lower TPB values.
Attitude | “This is a major issue (mental health). Because of the stress, there are always sick leaves. The bitching among each other increases, the employees walk around with grumpy faces.” | |
Organizational Norms | ||
Perceived Behavioral Control (internal) | ||
Perceived Behavioral Control (external) |
Nevertheless, it would have been desirable if we could have matched the statements of the managers with the assessments of their employees regarding their actual leadership behavior.
Leadership behavior has a significant impact on the employees’ health (
We are aware that all qualitative research is contextual; it takes place within a specific time and place between two or more people (
Our study contributes to the research on health-related work design by showing that the theory of planned behavior (
In respect to managers
Our results on
Our results on
Practical approaches to foster managerial support of health-related work design interventions according the dimensions of the Theory of Planned Behavior model.
Attitude | To reach all managers who are not yet sensitized for the issue of mental health promotion. To reduce role conflicts, e.g., by demonstrating that employee health and performance orientation are not necessarily opposites. |
Organizational Norms | To establish a credible and transparent communication process on the importance of mental health promotion in hospitals. To develop participative strategic and operational goals and measures to promote the mental health of employees who are integrated into existing structures. |
Perceived Behavioral Control | To develop the managers’ skills needed to implement work design measures. To provide managers with necessary resources to implement work design measures. |
Our qualitative findings might stimulate future studies that further validate our results. Moreover, our findings might further guide the development of interventions to improve health-related work design in hospitals. These measures are important to reduce the risk of impaired mental well-being among hospital staff and increase job satisfaction, which in turn have a positive effect on the quality of patient treatment.
The interview study was embedded in the cluster-randomized collaborative study “Mental Health in the workplace hospital” (SEEGEN), which aims to develop and implement behavioral and relational interventions to reduce stress in hospitals (
The data sets generated for this study will not be made publicly available. The data supporting the results of this study can be requested from MG, but restrictions apply if the use could endanger the anonymity of the participants.
The studies involving human participants were reviewed and approved by the Ethics Committee of the Medical Faculty, University Düsseldorf. The patients/participants provided their written informed consent to participate in this study.
AM developed the study concept. MG and BW performed the data collection. MG performed the data analysis and interpretation, and drafted the manuscript. AM, PA, and BW provided the critical revision of the manuscript. All authors designed the study and approved the final version of the manuscript for submission.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.